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EMR Order Alert Significantly Decreases Vitamin D Testing at Kaiser Permanente

Thomas S. Lorey, MD, FCAP

Identification and treatment of vitamin D deficiency is important for musculoskeletal and extra-skeletal health. For serum vitamin D testing of at-risk populations, there are well-defined clinical indications, including osteoporosis, malabsorption, fracture, limited effective sun exposure, obesity, and institutionalized individuals, among others. In these individuals it is appropriate to measure vitamin D to determine the dose of oral vitamin D supplementation to reach target levels. Repeat testing to ensure replenishment is also warranted.

However, there is little evidence to support broad-based screening for vitamin D deficiency in otherwise healthy individuals. Normal-risk adults do not need assessment of vitamin D levels; they need appropriate dietary intake of vitamin D. Nonetheless, despite the recommendation of evidence-based guidelines, vitamin D testing has significantly increased nationwide.

Nowhere was the increased utilization of vitamin D testing more evident than at Kaiser Permanente in Northern California, where volume increased 224% over the course of three years, outstripping the population growth of 2% by 222%. The increased testing was evenly distributed across the region and disproportionally increased when compared to other baseline tests such as those for complete blood count and electrolytes.

Because there had been no significant change to testing guidelines that require vitamin D testing—for example clinical indications or at-risk population—the increased utilization likely arose from the extensive media coverage of conflicting and nonconclusive studies associating vitamin D levels with a wide spectrum of illness and disease. Despite the lack of evidence and expert recommendation, it seemed plausible that heightened public awareness/concern had driven the increased testing.

Julia Drees, PhD

The test for vitamin D deficiency had been steadily increasing in frequency at Kaiser until Julia Drees, PhD, technical director of chemistry, and Thomas S. Lorey, MD, laboratory director, and their colleagues decided to confront what they hypothesized was inappropriate utilization due to widespread misunderstanding of test indication. Dr. Drees believed that much of the testing could be attributed to routine screening of otherwise healthy adults. The regional laboratories were performing approximately 2,000 vitamin D tests every day; and it was time to act—further growth was not sustainable.

"Vitamin D testing was the poster child of overutilization; it was truly overwhelming how much it was going up year over year. From 2008 to 2011, it went up more than 200% in frequency," said Dr. Drees, who went on to explain that the highly effective and widely used hemoglobin A1C test took twice the amount of time to grow to half the rate of order frequency as the vitamin D test. Unlike vitamin D, the increase in A1C volumes was accompanied by new indications for A1C testing.

Despite the near-universal popularity of the vitamin D test, little evidence supported its inclusion in general screens for otherwise well patients, according to Dr. Drees. Not only was there little research supporting the test's use in general screens, but the reference points were not population based. They also were set far too high without a proper medical decision point, making any analysis of patient results or diagnosis more like guesswork, according to Dr. Lorey.

He continued, "So we were not only testing individuals that didn't require testing, we were flagging folks who were clearly not deficient in vitamin D. And combined with all of this, a readily available treatment—or prevention, if you will—already existed by taking vitamin D supplements."

"What you end up with is a lot of hype for what turns out to be a low-value test," added Dr. Drees.

With Dr. Drees and Dr. Lorey, along with their colleagues, aware of the economic, time, and care costs of the test, they decided that a proper utilization initiative was required before their laboratory (and the rest of the system) became more embroiled in the volume of unnecessary testing.

The first step in their plan was to get support from clinical partners, so they went to the physicians most familiar with the issue.

"Getting the endocrinologist on board was critical," said Dr. Lorey, who went on to say that the endocrinologists at Kaiser, being experts in diagnostics and treatment, had also noticed the prevalence of vitamin D testing and were willing to lend their support.

The team then presented their plan to administrators at the executive level, who once brought up to speed, supported the initiative to go forward with placing a best practice alert in the electronic medical record (EMR). Displayed at the time of test ordering, the alert simply reminded providers that routine screening of healthy, low-risk individuals for vitamin D deficiency was not recommended. The alert also included a recommended daily intake of 600 to 800 international units of vitamin D.

Clinicians were quick to correct course. Within several months, vitamin D testing volumes had decreased by 40%, a reduction that has been sustained over time. Because the alert was passive and simply advised appropriate indications for testing, it seemed clear that vitamin D testing in Kaiser's Northern California health system was often being added as a routine screening test to otherwise well patient visits, contrary to indication.

While there was some physician pushback with the new pop-up alert, both Dr. Drees and Dr. Lorey were impressed how quickly volumes have decreased and how long the reduction has been sustained.

"I think there was a realization among the primary care physicians that this was of no value and was creating an enormous amount of work for them, not to mention potential anxiety and confusion among our patients," Dr. Lorey said. "If you're told your level [of vitamin D] is low and you Google that, you might all of a sudden jump to the conclusion that you have osteoporosis or rickets or some other disease."

A simple statement in the test order that the vitamin D testing may not be indicated in their patient was all it took.

Cost savings to the laboratory approach $1 million annually, though Dr. Lorey noted that the real cost savings came in provider and patient time—resources wasted on explaining the test, reviewing and explaining the results, and, regardless of results, explaining and recommending appropriate vitamin D intake. "The downstream cost in terms of time sink and distraction of both patients and providers is significant, albeit difficult to quantitate; I think that’s where we’ll find the real savings."

Considering the larger trends in health care, the evolution to a health system focused on the quality and value of patient care can be achieved through systemwide steps that start with the laboratory working with clinical partners and executives, according to both Dr. Drees and Dr, Lorey.

"This is an example of a test that has been used in many cases without indication and without benefit to patient health or outcomes," said Dr. Lorey. "It's ultimately wasteful and represents inappropriate financial stewardship of the health care dollar."

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